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Hum. Reprod. Advance Access published online on May 27, 2009
Human Reproduction, doi:10.1093/humrep/dep098
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© The Author 2009. Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology. All rights reserved. For Permissions, please email: journals.permissions@oxfordjournals.org

World Collaborative Report on Assisted Reproductive Technology, 2002

International Committee for Monitoring Assisted Reproductive Technology (ICMART):, Jacques de Mouzon1,9, Paul Lancaster2, Karl Gosta Nygren3, Elisabeth Sullivan4, Fernando Zegers-Hochschild5, Ragaa Mansour6, Osamu Ishihara7 and David Adamson8

1 INSERM U822, Hôpital de Bicêtre, 82 rue du Général Leclerc, 94276 Le Kremlin Bicêtre Cedex, Paris, France 2 Australian Health Policy Institute, School of Public Health, University of Sydney, Sydney, Australia 3 IVF Unit, Sophiahemmet Hospital, Stockholm, Sweden 4 Perinatal and Reproductive Epidemiology and Research Unit, School Women's and Children's Health, University of New South Wales, Sydney, Australia 5 Unit of Reproductive Medicine, Clinicas las Condes, Santiago, Chile 6 3 Rd 161, Maadi, Cairo 11431, Egypt 7 Saitama Medical University Hospital, Moroyama, Saitana 350-0495, Japan 8 Fertility Physicians of Northern California, Palo Alto and San Jose, CA, USA

9 Correspondence address. Fax: +33-58-41-18-70; E-mail: jacques.demouzon{at}inserm.fr


   Abstract
Top
 Abstract
Introduction
 Materials and Methods
 Results
 Discussion
 Conclusion
 List of contributors
 Supplementary data
 Funding
 References
 
The International Committee for Monitoring Assisted Reproductive Technology's (ICMART) Eighth World Report analyzes assisted reproductive technology (ART) practice and results for the year 2002 from 53 countries by type of ART, women's age, number of embryos transferred and multiple births. Over 601 243 initiated cycles resulted in a delivery rate (DR) per aspiration of 22.4% for conventional IVF, 21.2% for ICSI and a DR per transfer of 15.3% for frozen embryo transfer. For conventional IVF and ICSI, there was an overall twin rate of 25.7% per delivery and a triplet rate of 2.5%. The number of babies born worldwide through ART in 2002 was estimated to range between 219 000 and 246 000. There were wide variations in availability, DRs and multiple birth rates across the countries. Compared with the previous report (year 2000), there was a large increase in the number of cycles and a slight increase in the DR. There was a marginal decline in the mean number of embryos transferred and in the multiple DRs.

Key words: assisted reproductive technology/registries/outcomes/multiple pregnancies/public health


   Introduction
Top
 Abstract
 Introduction
Materials and Methods
 Results
 Discussion
 Conclusion
 List of contributors
 Supplementary data
 Funding
 References
 
This is the Eighth World Report on assisted reproduction technologies (ART) produced by The International Committee for Monitoring Assisted Reproductive Technology (ICMART), since 1989 (IWGROAR et al., 1993Go, 1995Go, 1997Go, 1998Go, 2001aGo, bGo; ICMART et al., 2006Go). It represents an overview of the World practice and results in ART for the year 2002 and allows comparisons between countries and regions, and analysis of trends by comparing to the previous reports.


   Materials and Methods
Top
 Abstract
 Introduction
 Materials and Methods
Results
 Discussion
 Conclusion
 List of contributors
 Supplementary data
 Funding
 References
 
Data were collected as follows. Five regional registers gathered data either from national registries (Europe, North America and Australia–New Zealand—ANZ) or from individual ART units (Latin America and Middle East). In Asia and Israel, data were sent directly to ICMART from national registries.

The ICMART data collection uses forms describing the organization of each country register and the results of IVF, ICSI and frozen embryo transfer (FET): initiated cycles, aspirations, transfers, clinical pregnancies, deliveries and newborns. These variables are further classified according to the fertilization technique, women's age, number of embryos transferred and gestational age at delivery. Other forms describe preimplantation genetic diagnosis (PGD), oocyte donation (OD), immediate complications for women and congenital anomalies detected during the perinatal period. The ICMART-World Health Organization glossary (ICMART et al., 2002Go, Zegers-Hochschild et al., 2006aGo, bGo) was used as reference for terminology. The report covers ART initiated during the year 2002 and is based on aggregated country data.

Data are presented by country and region. When the number of initiated cycles was unavailable in a register, estimation was made by applying the average cancellation rate (9.4%) calculated among countries with available data to its number of aspiration cycles. For registries with incomplete coverage, the number of initiated cycles per country was estimated by dividing the reported number by the percentage of participating clinics. A similar estimation was done for the number of ART babies. Finally, the total number of babies born worldwide from 2002 ART procedures was estimated using the hypothesis that the missing countries, mostly in Asia, Africa, Oceania and West Indies, performed between 10% and 20% of the World activity in ART. Availability is expressed as the number of cycles (estimated) per million inhabitants in 2002 (The World Factbook, 2003Go). A cumulative delivery rate (DR) per aspiration was estimated by adding the FET deliveries to those obtained from fresh cycles and dividing the sum by the number of aspirations.


   Results
Top
 Abstract
 Introduction
 Materials and Methods
 Results
Discussion
 Conclusion
 List of contributors
 Supplementary data
 Funding
 References
 
Data were received from 1563 clinics in 53 countries (134 clinics and 5 more countries than in 2000). These clinics represented 66% of all registered clinics in those countries, and 27 countries reported a complete coverage (Supplementary Table I). The report covers an estimated total of 601 243 cycles from the participating clinics (+25.6% since 2000). The USA reported the largest number of aspirations, followed by Germany and France (Table I). On a regional basis, Europe had the largest contribution (56.4%). Overall, FETs represented 21.7% of the aspiration number (14.4% in 2000). This proportion fluctuated from >64% in Finland, Australia and Switzerland to <10% in 23 countries. ICSI represented 56.6% of fertilization procedures (47.6% in 2000), reaching 75.9% in Latin America and 92.4% in the Middle East. The availability of ART varied from two cycles per million inhabitants in Ecuador to 3688 in Israel.


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  		Table I General data: distribution of procedures, year 2002

 
Table II reports the ART outcomes. Pregnancy rates (PRs) and DR per aspiration were very similar in IVF and ICSI (28.2% versus 29.2% and 22.4% versus 21.2%). For FET, PR and DR per transfer were 21.5% and 15.3%. DR increased since 2000 (18.6% for IVF, 20.4% for ICSI and 12.0% for FET). When combining IVF and ICSI, DR per aspiration was 22.3% for the ‘fresh’ cycles and 25.7% for the cumulative rate (fresh + frozen cycles). Cumulative DR per aspiration varied among countries from 14.3% to 39.3%, being the highest in North America (37.5%). In total, 148 208 babies were reported.


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  		Table II IVF, ICSI and FET results for 2002

 
The proportion of women aged 40 years or older was 14.2%, similar to 2000, varying from 2.1% in Croatia to 22.4% in Japan (Supplementary Table II). The DR per aspiration was 9.4% at 40 years or more, and spontaneous miscarriages increased from 28.8% in women <35 years to 43.7% for those ≥40 years (Supplementary Fig. 1).

The percentage of transfers with four or more embryos decreased since 2000 from 15.4% to 13.7% (Table III) in fresh cycles, remaining high in South Korea (53.7%), Latin America (37.9%), India (37.2%) and UAE (37.2%), but low (0–0.5%) in 11 countries in Europe and Australia. The proportion of single embryo transfers increased from 10.5% to 12.4%, highest in Finland (38.5%), Sweden (30.5%) and Australia (25.0%). Overall, the proportions of twin and of triplet pregnancies decreased since 2000 (from 26.5% to 25.7% and from 2.9% to 2.5%). The triplet DR varied markedly, from 0.2% in Finland and Sweden to >10% in Guatemala and UAE. The mean number of embryos transferred (Supplementary Fig. 2) was correlated with the triplet rate (r = 0.48, P < 0.001), but not with DR (r = 0.02, NS). The same developments were seen for FET, with a lower rate of multiple pregnancies (Supplementary Table III). The percentage of premature babies (<37 weeks) increased from 13.5% for singletons to 61.3% for twins and 94.2% for triplets (Supplementary Fig. 3). The same was true for perinatal mortality (10.7, 29.6 and 71.2 per 1000 babies) (Table IV).


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  		Table III IVF and ICSI cycles: number of transferred embryos, efficacy and safety for 2002

 

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  		Table IV Pregnancy losses, prematurity and perinatal mortality for 2002

 
The abortion rate per clinical pregnancy was, on average, 20.0% in fresh cycles, with large differences (2.4–47.3%), and higher in FET pregnancies (25.2%, P < 0.001).

Only 14 countries reported 3187 PGD cycles with PR and DR per aspiration at 23.0% and 17.6% (Supplementary Table IV). Furthermore, 31 countries reported OD (Supplementary Table V). Out of 21 914 OD transfers, 54.1% were done in the USA and 70.8% were fresh embryos transfers. For fresh transfers, PR and DR per transfer were 52.1% and 39.1%. For OD-FET, PR per transfer was lower (30.5%). The total number of reported babies was 10 108 (8800 in USA). Europe reported 2174 pregnancies but not the deliveries and births.

The frequency of ovarian hyperstimulation syndrome was reported by 34 countries, at 0.8% (range 0.3%–6.6%). Congenital anomalies were poorly reported (Supplementary Table VI).

Finally, taking into account the missing centres, it was estimated that ART produced 196 981 babies from 820 280 cycles in the participating countries. By extrapolation, it was estimated that 219 000–246 000 babies were born worldwide from an estimated 911 000 to 1 025 000 cycles, an increase of 12% compared with the year 2000.


   Discussion
Top
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
Conclusion
 List of contributors
 Supplementary data
 Funding
 References
 
The ICMART World report gives a broad overview of the World ART practice and results for 2002, even though there are some methodological problems (Cohen, 2001Go).

Methodological problems
Several large countries did not report data: China, Pakistan, Bangladesh, Indonesia, Philippines, Turkey and all of sub-Saharan Africa, Also, one-third of the clinics in the participating countries did not report to their national registers. We hypothesized that ART was less frequent in the missing countries and would contribute 10–20% of the world ART activity, and that missing clinics had the same level of activity and results as the reporting clinics, which can be debated. With these assumptions, it can be estimated that this report would cover 60–70% of the World ART activity. ICMART is continuing efforts to improve data collection, and it is encouraging that 27 countries had a complete reporting from all clinics.

Many countries submitted incomplete data, mostly due to the pyramidal organization of data collection: data were exported from clinics to countries, then to regions and then to ICMART. This allowed each clinic to complete forms only once, but complicated efforts to develop a common standardized data form at the different collection levels. However, the major outcome variables (procedures, pregnancies, deliveries and babies) are the same in all the registries.

Moreover, the ICMART-WHO glossary definitions (ICMART et al., 2002Go, Zegers-Hochschild et al., 2006aGo, bGo) are likely not always utilized, even though the glossary has been endorsed by most large international professional organizations. One illustration is the wide variation in abortion rates among the countries (2.4–47.3%), far too large to be explained only by chance. This reinforces the necessity of encouraging all professionals to utilize the glossary and to report DR per cycle initiated (intention to treat) or at least per aspiration.

Thus, variation in data quality, added to differences in practices, legislation, guidelines, culture and religion, means that comparisons among countries must be done with caution. However, it is far better to have imperfect but improvable data than no data at all (Adamson et al., 2001Go). Large differences can be identified, explored in specific studies and time-trends followed.

Trends and general considerations
This report shows a continuous increase in the number of aspirations in participating countries (+16.0% since 2000). There are wide differences in availability, with many potential reasons such as fertility rate, women's age, insurance coverage, national economy etc., but the most important is certainly inequality in the access to healthcare and ART.

The use of ICSI is increasing worldwide (from 54.4% in 2000 to 60.8% in 2002 in North America, from 45.7% to 53.9% in Europe), and reached 76.1% in Latin America and 92.5% in Middle East in 2002. Since there is no reason to believe that there is such an increase in male infertility, the reasons behind this trend are difficult to know, since ICSI has not been demonstrated to improve results for non-male infertility treatment.

One of the major public heath problems in ART is the high rate of multiple births, with serious consequences for both maternal and newborn health. It is encouraging to note a decrease in the mean number of transferred embryos and multiple birth rate in almost all countries. However, as one triplet pregnancy results in three triplet babies, this means that 14.6% of ART babies were triplet in Latin America, 10.9% in the Middle East (two regions where no embryo reduction is available), 8.2% in the USA, 3.1% in Europe and 2.0% in ANZ. The fact that the average number of transferred embryos was not related to PR, after more than two are transferred, that the average number of embryos transferred was reduced and that DR per aspiration was increased in 2002 should encourage embryo transfer policies that reduce the risk of multiple birth.

Another benefit of lowering the number of embryos transferred fresh is that it results in more embryos available for freezing and more FET, probably explaining the major FET increase reported in 2002 (+47%). To better evaluate ART results, it is necessary to use a cumulative PR, adding to the fresh pregnancies the additional FET pregnancies resulting from the same aspiration. The ICMART cumulative rate is not methodologically perfectly correct, since we sum the fresh and frozen pregnancies of the same year, whether they come from the same aspiration or not. This calculation approximates the correct result if the proportions of aspirations and FET remain constant over time, but may slightly underestimate the actual rate if there is a relative increase in FET. Even imperfect, it is currently the only way to approximate the actual results of aspirations since FET can be performed several years later. This calculation is of major importance to compare countries or centres. For example, in Australia, the DR per aspiration was at 19.5% for fresh cycles and at 29.4% for the cumulative rate (mean number of transferred embryos 1.8), whereas the gain was less in Latin America (24.4–26.0%, 3.1 embryos transferred).

Maternal complications and congenital anomalies were poorly reported, due to the lack of standardized terminology and diagnosis, to the sometimes high rate of loss to follow-up and also because a certain proportion of anomalies are not discovered until after the time covered by the reporting period. Therefore, data on birth defects need other data collection strategies.


   Conclusion
Top
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 Conclusion
List of contributors
 Supplementary data
 Funding
 References
 
This World Report shows a general increase in ART activity over time. PR and DR have increased despite a decrease in the number of embryos transferred, accompanied by a decrease in the percentage of multiple pregnancies. There are still large differences among countries. Europe and ANZ continue to lead the way in the reduction of multiples with triplet rates approximately half those of the USA and 5-fold less than Latin America, whereas the USA continues to have the highest PRs. Consistent with a decrease in the number of embryos transferred, the proportion of FET is increasing 2-fold faster than oocyte aspiration cycles. From this report, the total number of babies born through ART worldwide in the year 2002 is estimated to be between 219 000 and 246 000.


   List of contributors
Top
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 Conclusion
 List of contributors
Supplementary data
 Funding
 References
 
Australian and New Zealand Assisted Reproduction Database (ANZARD), Fertility Society of Australia/AIHW National Perinatal Statistics Unit, European IVF Monitoring (EIM) Consortium, Latin American Network for Reproductive Medicine (RED), Society for Assisted Reproductive Technology (SART)/Centres for Disease Control (CDC), Middle East IVF registry and all the participating countries (ART centres participating in the ICMART 2000 World Report are listed in Supplementary data).


   Supplementary data
Top
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 Conclusion
 List of contributors
 Supplementary data
Funding
 References
 
Supplementary data are available at http://humrep.oxfordjournals.org/.


   Funding
Top
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 Conclusion
 List of contributors
 Supplementary data
 Funding
References
 
ICMART receives financial support from the following organizations: American Society for Reproductive Medicine (ASRM), Bertarelli Foundation, European Society for Human Reproduction and Embryology (ESHRE), Fertility Society of Australia (FSA), Latin American Network for Reproductive Medicine (RED), Middle East Fertility Society (MEFS) and Society for Assisted Reproductive Technology (SART).


   References
Top
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 Conclusion
 List of contributors
 Supplementary data
 Funding
 References
 
Adamson GD, Lancaster P, de Mouzon J, Nygren KG, Zegers-Hochschild F. A simple headstone or just eliminate the chads? Fertil Steril (2001) 76:1284–1285.[CrossRef][Web of Science][Medline]

Cohen J. The future of international registries for assisted reproductive technologies. Fertil Steril (2001) 76:871–873.[CrossRef][Web of Science][Medline]

Vayena E, Rowe PR, Griffin PD. ICMART. Glossary prepared by ICMART. In: Current Practices and Controversies in Assisted Reproduction. Report of a WHO Meeting (2002) Geneva: WHO. xix–xxi.

ICMART, prepared by Adamson D, de Mouzon J (Coordinator), Lancaster P, Nygren KG (Chairman), Sullivan E and Zegers-Hochschild F. World collaborative report on in vitro fertilization 2000. Fertil Steril (2006) 85:1586–1622.[CrossRef][Web of Science][Medline]

IWGROAR, prepared by Cohen J, de Mouzon J, Lancaster P. World collaborative report on in vitro fertilization, 1991. VIIIth Congress on In Vitro and Alternate Assisted Reproduction, Congress Booklet, Kyoto, 12–15 September 1993. 1–38.

IWGROAR, prepared by de Mouzon J, Lancaster P. World collaborative report on in vitro fertilization, 1993. Congress Booklet, Montpellier, 17–22 September 1995. 1–43.

IWGROAR, prepared by de Mouzon J, Lancaster P. World collaborative report on in vitro fertilization. Preliminary data for 1995. J Assist Reprod Gen (1997) 14:251s–265s.

IWGROAR, presented by de Mouzon J, Lancaster P, Nygren K, Zegers-Hochschild F. World report: preliminary data for 1996. 16th World Congress on Fertility and Sterility, IFFS, San Francisco, USA, 4–9 October 1998.

IWGROAR, prepared by Adamson D, Lancaster P, de Mouzon J (co-ordinator), Nygren KG (chairman) and Zegers-Hochschild F. World collaborative report on assisted reproductive technology, 1998. IFFS, Melbourne, 25–29 November 2001a.

Healy DL, Kovacs GP, McLachlan E, Rodriduez-Armas O. IWGROAR, prepared by Adamson D, Lancaster P, de Mouzon J (co-coordinator), Nygren KG (chairman) and Zegers-Hochschild F. World collaborative report on assisted reproductive technology, 1998. In: Reproductive Medicine in the 21st Century (2001) b. London, UK: Parthenon Publishing Group. 209–219.

The World Factbook. (2003) http://www.umsl.edu/services/govdocs/wofact2003/.

Zegers-Hochschild F, Nygren KG, Adamson D, de Mouzon J, Lancaster P, Mansour R, Sullivan E. The International Committee Monitoring Assisted reproductive Technologies (ICMART) glossary on ART terminology. Fertil Steril (2006) a 86:16–19.[CrossRef][Web of Science][Medline]

Zegers-Hochschild F, Nygren KG, Adamson GD, de Mouzon J, Lancaster P, Mansour R, Sullivan E, on behalf of The International Committee Monitoring Assisted Reproductive Technologies. The ICMART glossary on ART terminology. Hum Reprod (2006) b 21:1968–1970.[Abstract/Free Full Text]

Submitted on May 31, 2008; resubmitted on January 14, 2009; accepted on March 5, 2009.


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